Barium follow through and small bowel enema sahara mahato

PRESENTED BY:
Sahara mahato
B.Sc. MIT 2ND YEAR
ROLL NO:96
IOM, MAHARAJGUNJ MEDICAL CAMPUS

The alimentary canal doesn't have sufficient density to be
demonstrated through surrounding structures, so its
radiographic demonstration requires the use of artificial
contrast medium (barium).
Barium examinations require use of high KVp technique to
penetrate barium (>90KVp).
Barium follow through & small bowel enema are two basic
types examinations to examine small bowel in its entirety i.e.
to evaluate functional capabilities as well as morphological
abnormalities.
2Barium follow through & small bowel enema

Extends from pyloric sphincter of stomach to ileoceacal
valve, where it joins large intestine at right angle.
Lies in abdominal cavity surrounded by large intestine
About 6.5 m long & diameter gradually decreases from
about 3.8 cm in proximal part to approximately 2.5 cm in
distal part.
Wall contains 4 layers- serosa, muscle layer, submucosa &
mucosa. Mucosa contains finger- like projections called
villi.
Divided into 3 portions:
a) Duodenum,
b) Jejunum &
c) Ileum

About 25 cm long & widest part.
Begins at pylorus & curves around the head of pancreas as
“C”.
Constitute 4 portions:
1. First (superior): duodenal bulb
2. Second (descending): common bile duct & pancreatic duct
usually unites to form hepatopancreatic ampulla, which
opens on greater duodenal papilla.
3. Third (horizontal or inferior)
4. Fourth (ascending): joins jejunum at a sharp curve called
duodenojejunal flexure & is supported by suspensory
muscle of duodenum (ligament of Treitz)

Jejunum is the middle
section of small intestine & is
about 2.5 m long.
Ileum is the terminal section
about 4 m long, leads into
large intestine at ileoceacal
valve.

Barium follow through & small bowel enema 6

Barium Follow Through is performed to demonstrate small
bowel
Demonstrates from the duodenum to the ileoceacal region
encompassing the duodenum, jejunum and ileum including
the junctions superiorly with the stomach and inferiorly
with the ascending colon
 by oral administration of contrast media (Barium).
BFT may be performed as a continuation of an upper
gastrointestinal (UGI) series or as a separate. it can permit
better evaluation of small bowel motility than does
enteroclysis (small bowel enema)
Also known as barium meal follow through (BMFT) if followed
to Ba. Meal & small bowel follow through (SBFT) but we call it
BFT in this presentation.

Single Contrast
Double Contrast (with addition of an effervescent
agent)
Peroral Pneumocolon.
Note: Double contrast technique is normally adopted.

Suspected Tubercular Lesion
Diarrhoea
Partial Obstruction
Lesions such as strictures, neoplasms, Mekels
diverticulum
Pain
Mal-absorption /Dyspepsia
Crohn’s disease (most common)
Abdominal Mass
Loss of weight
Anaemia (Gastro-intestinal Bleeding)
Usually in case of equivocal follow through

Complete Bowel Obstruction
Suspected Perforation
Paralytic ileus
Very ill Patient
Recently Operated Patient
Pregnancy (benefits vs risks)

Barium sulphate solution 100% w/v 300 ml (150 ml if
performed immediately after barium meal)
Usually given in 10-15 min increments or full at once
Transit time through small bowel has been shown to be
reduced by the addition of 10 ml of gastrograffin to
barium.
For children,3-4 ml/kg is suitable volume of contrast.
In situations where barium is contraindicated, non-
ionic water soluble solutions are used.

High power x-ray generator
Spot film device
Fluoroscopic unit with II TV system
Tilting type of x-ray table
Over- couch x-ray tube.
Compressing cup

Accurate & clear history must be obtained from pt. for e.g., in
the case of insulin- dependent diabetes, the best time for
stopping eating can be arranged.
A low residue- diet for 2 days prior to the examination.
A laxative should be taken on the evening prior to the
examination.
NPO for 6 hrs prior to examination
Metoclopramide 20 mg orally given 20 min before or during the
examination to enhance gastric emptying.
Pt’s bladder must be empty before & during procedure to avoid
displacing or compressing ileum.
Pt must be informed that the barium may taste chalky.
Pt must remove all the clothing & jewelry & wear a hospital
gown.

Plain radiograph of the abdomen.
To see bowel preparation.
To rule out contraindication.
helps in assessing any abnormalities of gas filled
bowel loops.
If residual fecal matter present-examination should
be cancelled.

Patient is asked to drink Barium Suspension as
rapidly as possible and then put the patient on right
side.
Give dry food if transit time is slow.
If follow through is combined with barium meal,
glucagon is used instead of buscopan for duodenal
cap view.

Prone PA films of the abdomen are taken.
 The first radiograph is taken 15 min following the
drink, with the second image at 30 min. Then the
radiographs are taken at 30 min intervals until the
barium has reached terminal ileum.
 Pressure on the abdomen helps to compress
abdominal contents so that the loops of small bowel
are separated. Thus for better radiographic quality,
prone position is used.
Spot films of the terminal ileum are taken supine.

• Compression pad is used in right iliac fossa to displace
any overlying loops of small bowel that are obscuring
terminal ileum.
Supine position is used for
 Superior & lateral shift of barium filled stomach
 For visualizations of retrogastric portions of duodenum
& jejunum
 To prevent possible compression overlapping loops of
intestine.

To separate loops of small bowel
-compression with fluoroscopy
-Oblique view
-x-ray tube Angled into the pelvis.
-Patient tilted head down.
To demonstrate Diverticula
-Erect (Reveals fluid level within the
diverticulum by CM).

Same as single contrast study.
BUT IN DC,
 Gas producing agent is given when head of Barium
column reaches the caecum. This should generate about
750-1000 ml of gas.
Pt is placed on the left side slightly head down
(Tredelenberg position) to allow the gas to leave the
stomach & enter the small bowel.
Compression radiographs with patient in supine or oblique
positions are taken.
Modifications: Lacquer- coated effervescent tablets to
provide a select release of gas in small bowel.

Improved mucosal detail.
Better distension.
Separation of loops.
Effective for young patients & those who are unable
to swallow the enema tube.

The peroral pneumocolon(POPC) examination is a
method for obtaining a double-contrast image of the
terminal ileum and right colon by insufflating air through
a small catheter inserted into the rectum when orally
ingested barium reaches the right colon
The indications for the peroral pneumocolon examination
are
(1) Polyps are present in the right colon
(2) clinically suspected inflammatory bowel disease with
an apparently normal terminal ileum,
(3) an abnormal terminal ileum with equivocal fistulae
(4) when patients are unable to tolerate barium enema
studies.

When orally ingested barium reaches the right
colon, air is advanced through a small catheter
inserted into the rectum. Spot views of the different
areas of small bowel especially the terminal ileum
are taken.
Compression may be used.

Requires colon cleaning for an adequate study.
Uncomfortable procedure for the patient.
Reflux sometimes not possible in~10% cases.
Long procedure time.

Inform the pt that his bowel motions will be white
for few days after the examination & may be difficult
to flush away.
Advise to drink adequate volume of water to avoid
Barium impaction. (Laxative may be taken if
required)
Pt should not leave the department till any blurring
of vision produced has resolved.

Leakage of Barium suspension from unsuspected
perforation.
Aspiration of Barium.
Conversion of partials obstruction into complete
obstruction by impaction of Barium.
Barium Appendicitis (if Barium impacts in
Appendix)
Side effect of pharmacological agents used.

Easily performed.
No discomfort/intubation to the patient like
Enteroclysis.
It is a physiological process. Hence transit time
can be assessed.
Disadvantage of BMFT
Overlapping of Barium filled bowel loops in the
pelvis.
Poor distension of bowel loops.

Ileo-vesical Fistula

Small bowel is demonstrated following duodenal
intubation rather than by oral administration of
contrast as in BMFT.

Suspected Tubercular Lesion
Diarrhoea
Partial Obstruction
Lesions such as strictures, neoplasms, Mekels
diverticulum
Pain
Mal-absorption /Dyspepsia
Crohn’s disease (most common)
Abdominal Mass
Loss of weight
Anaemia (Gastro-intestinal Bleeding)
Usually in case of equivocal follow through

Recently operated patient/ GI Surgery
Uncooperative patient
Complete obstruction
Suspected perforation
Pregnancy (Risks Vs Benefits)

Single contrast (SC)
Double contrast (DC)

Single contrast method: Barium sulphate solution
70 % w/v is diluted to give 1500 ml of 20 %
solution.
Double contrast method: 600 ml of 0.5 %
methylcellulose after 500 ml of 70 % w/v barium
sulphate solution.

In addition with the equipments needed
for barium follow through, the following
needed.
For contrast administration, two
types of tubes are available:
 Bilbao- dotter tube with guide wire
 Silk tube with tungsten filled guide
-tip. It is made up of polyurethane &
the stylet & internal lumen of the
tube are coated with water
- activated lubricant to facilitate
the smooth removal of the stylet
after insertion. 43Barium follow through & small bowel enema
Silk tube

A low residue- diet for 2 days before the
examination.
A laxative should be taken on the evening prior to
the examination.
NPO for 6 hrs prior to examination
If the patient is taking any antispasmodic drugs,
they must be stopped 1 day prior to examination.
Amethocaine lozenge 30 mg, 30 min before the
examination.

Plain abdominal film if a small bowel obstruction
is suspected.

The patient sits on the edge of x-ray table. The pharynx is
anaesthetized with lignocaine spray.
The tube is then passed through nose or mouth with brief lateral
screening. If per nasal approach is planned the patency of the
nasal passage is checked by asking the patient to sniff with one
nostril occluded.
 The Silk tube should be passed with the guide wire pre-
lubricated & fully within the tube.
 For Bilbao- dotter tube, the guide wire is usually introduced
after the tube tip is in stomach.
The patient is asked to swallow with neck flexed as the tube is
passed through the pharynx. The tube is then advanced into the
gastric antrum.

The pt then lies down & the tube is passed into duodenum.
 Lie the pt on the left side so that the gastric air bubble rises to
the antrum, thus straightening out the stomach.
 Advance the tube whilst applying clockwise rotational motion
(as viewed from the head of the pt looking towards feet).
 In the case of the Bilbao-Dotter tube, introduce the guide wire.
 In the case of the silk tube, lie the pt on right side, as the tube
has a tungsten-weighted guide tip which will then tend to fall
towards antrum.
 Get the pt to sit up to overcome the tendency of the tube to
coil in the fundus of stomach.
 Metoclopramide (20 mg i.v.) can be used.

When the tip of the tube has been passed
through pylorus, the guide wire tip is
maintained at the pylorus & the tube is
passed over it along the duodenum to the
level of ligament of Treitz. The tube is
passed as far as the duodenojejunal
flexure to diminish the risk of aspiration
due to reflux of barium into stomach.
Intubation technique
48
Barium follow through & small bowel enema

•Barium is then run in quickly at
the rate about 75 ml/min & spot
films are taken of the barium
column & its leading edge at the
regions of interest until the colon
is reached.
•Fluoroscopy is performed during
infusion & images are recorded
using digital acquisition, 100/105
mm film or full size radiographs as
required.
Single contrast technique

•Methyl cellulose is infused
continuously(100 ml/min) after initial
bolus of barium (100ml/min), until the
barium has reached the colon.
•The tube is then withdrawn, aspirating
any residual fluid in the stomach.
•Finally, prone & supine abdominal films
are taken.
Double contrast:

In patients with malabsorption, especially if an
excess of fluid has been shown on the preliminary
film,
 The volume of barium should be increased by
240-260 ml.
 Compression views of bowel loops should be
obtained before obtaining double contrast.
 It is important to obtain the images of
duodenum & the catheter tip should be sited
proximal to the ligament of Treitz.

Nil orally for 5 hrs after the procedure
The patient should be warned that diarrhoea may
occur as a result of large volume of fluid given.

Aspiration
Perforation of the bowel owing to manipulation of
the guide wire.

Gives better visualization of the small bowel unobstructed
by overlying barium filled stomach & duodenum.
Rapid infusion of large, continuous column of contrast
directly into jejunum avoids segmentation of barium
column & does not allow time for flocculation to occur.
Hypotonia caused by fluid overload makes demonstration
of lesions easier because abnormalities are more clearly
visible when the intestine is distended rather than
contracted.
As a result of the dilatation, minimal strictures, small sinus
tracts and fistulas, and minimal extrinsic compressions can
be visualized.

Intubation may be invasive & unpleasant for the
patient & may occasionally prove difficult.
It is more time-consuming for the radiologist.
There is higher radiation dose to the patient
(screening the tube into position).

A guide to radiological procedures- Chapman & Nakielny
Clark’s special procedures in diagnostic imaging
Merrill's atlas of radiographic positioning & procedures
Encyclopedia of radiographic positioning, vol.2
 http://radiology.rsna.org and
http://www.e-radiography.net
 Various internet sources

The amount of contrast medium for barium follow
through & small bowel enema?
Indications for barium follow through & small bowel
enema?
Contraindications for barium follow through & small
bowel enema?
Differences between barium follow through & small bowel
enema?
Complications of barium follow through & small bowel
enema?
Aftercare of BMFT.
Transit time for barium to reach IC Junction.
The role of compression pad in BMFT?

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